Alcohol and Drug Dependence Is Not a Mental Illness or Behavioral Disorder

Policy Position Paper #4 Alcohol and Drug Problems Association of North America

Alcohol and other drug dependence is a primary, chronic, progressive and potentially fatal disease. Its effects are systemic, predictable and unique. Without intervention and treatment, the disease runs an inexorable course marked by progressive crippling of mental, physical, and spiritual functioning with a devastating impact on all sectors of life- social, family, financial, vocational, educational, moral/spiritual, and legal.

Drug Addiction is a complex illness. It is characterized by compulsive, at times uncontrollable, drug craving, seeking, and use that persist even in the face of extremely negative consequences. For many people, drug addiction becomes chronic, with relapse possible even after long periods of abstinence.(1)

Alcohol and drug addiction is successfully treatable, and in the domain of public health, subject to prevention measures. Alcohol and drug dependence is not a mental illness or a behavioral health problem. It is a primary disease entity distinct from mental disorders. It should not be trivialized as a behavioral problem arising from personality disorders.

A substantial body of longitudinal studies on the psychological conditions of alcohol and drug dependent people have found that prior to developing alcohol and drug problems the subjects were no more likely to have mental disorders then the general population. (2)

Addictive use of alcohol and other drugs can cause temporary psychological and emotional problems. These problems are the result not the cause of the alcohol and other drug dependence. Mood swings, depression, and other psychological conditions are presented by alcohol and drug dependent people in the throes of their disease, and may become acute in the early withdrawal phase.

These conditions tend to be transitory in nature and are alleviated by a comprehensive abstinence-based regimen of recovery. The scientific literature fails to demonstrate the existence of an “alcoholic” or “addictive” personality in place prior to the onset of alcohol and other drug dependence. (3) A recently reported longitudinal study of 276 individuals entering substance abuse treatment found that, “Subjects recovering from an alcohol use disorder were 16.7 times more likely to recover from their mood/anxiety disorder than subjects who did not recover from their alcohol use disorder. Those recovering from an opioid use disorder were 4.3 times more likely to recover from a mood disorder than subjects who did not recover from an opioid use disorder.” (4) People with pre-existing mental conditions can become alcohol and drug dependent. In these cases, alcohol and other drugs can seriously exacerbate the mental disorders, and conversely, the mental problems can accelerate the progression of the alcohol and drug dependency and impede recovery. This “dually diagnosed” population, those with co-occurring mental disorders and alcohol/drug dependency, is receiving increased attention, and efforts are under way to establish systems offering appropriate treatment for both conditions. (5) Programs for the dually diagnosed require staff trained in both disciplines. Moreover, alcohol and drug dependency in this context is not treated as a symptom of a mental disorder or a secondary psychiatric diagnosis. (6)

The etiology of alcohol and other drug dependence is complex and not yet fully understood. Research increasingly points to biochemical abnormalities in the brain, and other physiological factors, strongly influenced by genetics. (7) Although many mental disorders may have similar origins, alcohol and drug dependency progresses on an independent course to its chronic stages characterized by increasingly destructive use of alcohol and other drugs, which in turn can cause new imbalances in brain chemistry. Unlike mental disorders and most other diseases, the progression stops and remission is achieved by the act of abstention-withdrawing from addicting intoxicating agents. It is the commitment to abstinence that is the unique measure of treatment for alcohol and drug dependence.

Alcohol and other drug dependency is cloaked in a stubborn and perverse stigma that in its worst form rejects even the concept that it is a disease. Rather, it is sometimes portrayed as “willful misconduct,” or the result of defective morals, flawed personalities or weak wills. (8) The stigma attached to illegal drug addiction adds the sinister dimensions of criminality and the entailing social opprobrium. Some aspects of the stigma have been perpetuated by theories and practices that attack the disease concept and maintain that alcoholics can be taught to moderate their drinking. Use of alcohol and other drugs by alcoholics and addicts is portrayed as a matter of personal choice, ignoring the powerful dynamics of addiction. The stigma has the effect of blaming the victims for their disease, and as such works as a barrier to treatment and an impediment to recovery. Additionally, the stigma induced shame interferes with the dependent person and their families ability to engage and succeed in treatment.

The view that alcohol and other drug dependence is a symptom of mental or behavioral disorders contributes to the stigma by promoting the perception that it is not a disease or public health problem in its own right.

Treatment regimens unique to addictions have been developed and refined over the past 50 years. Most models incorporate detoxification, treatment for medical consequences of use, comprehensive assessment, motivational counseling, education about the nature of the disease, family treatment, and group treatment, the core therapeutic vehicle for the recovering addict, Overcoming denial, surrender and readiness to change are treatment goals. Abstinence from alcohol and other addictive drugs is the sine quo non of post treatment success, with after-care focusing on relapse prevention and participation in 12-step and other self-help programs. Recovering alcoholics and addicts participate in the treatment process. As counselors, they are certified on the state and national levels through credentialing mechanisms developed over the past 25 years. The addictions field also pioneered the use of intervention techniques to speed entry into treatment.

The addiction model of treatment differs significantly from the traditional psychiatric model from the defining of the condition to the treatment goal itself. The table below highlights these differences.

The failure of professionals to recognize the distinctive nature of alcohol and other drug dependence has been a continuing concern of the Alcohol and Drug Problems Association. It leads to the misdiagnosis of patients and treatment in a mental health setting that is not only inappropriate but also potentially harmful. Psychotherapeutic methods that fail to underscore abstinence can delay recovery and potentially result in death.

Professionals in the addictions field believe in the need for clinical separation of their clients from traditional mental health models through the establishment of categorical programs focusing on alcoholism and drug dependence. Before the launching of the Federal alcoholism and drug abuse programs in the early 1970’s, the success of these efforts was limited. Hobbled by sparse public funding and limited third-party reimbursement, a relatively small number of programs offered treatment and rehabilitation to alcoholics and drug dependent people. In the absence of alternatives, alcoholics and drug addicts were admitted to psychiatric wards in state and veterans hospitals for the mentally ill.

The inception of the Federal alcoholism and drug abuse effort, with enactment of legislation by former Sen. Harold Hughes (D-IA), transformed the field with the rich infusion of grant funds for research and for the treatment of alcoholism and drug dependence through categorical programs. The establishment of the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse inaugurated a period of rapid proliferation of publicly funded programs and, with expanding insurance coverage for chemical dependency treatment, a vigorous private sector. A new body of treatment professionals arose, trained in the specifics of alcoholism and other drug abuse and dependence. For the first time in history, treatment became accessible to millions of alcoholics and drug addicts.

The Alcohol and Drug Problems Association believes that at present there is a new urgency for the need to safeguard the separate identity of treatment for alcohol and other drug dependence. Short-sighted economics inflicted by managed care practices have decimated the private treatment sector; many residential programs have had to close their doors; while others have been consolidated with mental health units. And purchasers of chemical dependency treatment services for the public sector, including Medicaid, and state, county and local agencies, are increasingly moving to the managed health environment, (ADPA Position Paper # 1). As result of shifting political priorities, publicly supported treatment systems in many states are under funded and unable to fill the treatment vacuum left by retrenchments in the private sector.

Most ominously, behind the drive to cut back on treatment for alcohol and drug dependence, is the unfounded proposition that treatment is ineffective, and if any is provided, it should be in the least costly setting. Yet study after study concludes there are positive results from treatment. (9)

Issue

Traditional Psychiatric Model

Addiction Model

Definition of addiction

Symptoms of underlying psychiatric disorder

Primary disorder in its own right

Treatment approach

Treatment underlying disorder

Treatment addiction directly

Referral once addiction discovered

To medical model program

To primary non-medical model including self-help groups

Attitude toward alcohol use and other drugs

Individualized, permissive

Absolutely against use, confrontive, total abstinence

Party primarily responsible for treatment

The professional

The patient

Role of trust

Important from early stages

Usually not attainable for months or longer

Admission criteria

Usually open

Usually selective

Role of psychoactive medication

Necessary for some underlying disorders; can be transitional substitute for alcohol

Limited to detoxification and deterrence (eg., disulfiram); further use may reinforce substance abuse

Role of family in treatment

Variable

Usually routine

Role of self-help groups

Variable, viewed as Superficial

Usually encouraged or required

Third-party involvement (eg., legal, employer)

Viewed as intrusive

Often arranged to aid treatment

Surveillance for compliance

Shunned, violates trust

Monitoring of disulfiarm, Breathalyzer checks for drinking, urinalysis checks for other drugs, often arranged

Coercion (eg., legal)

Last resort, interpreted as sign of failure

Frequently seen as useful

Treatment goals °

Cure (acute disorder), maintenance (Chronic disorder)

Rehabilitation, implying long- term work to maintain gains long-term work to maintain gains

Another development with threatening implications for the integrity of alcohol and drug dependency treatment has been a debasement of the diagnostic terminology. The term, “disease” has given way to the “disorder” of psychiatric coinage, and drug dependence is being placed under the crowded tent of “behavioral health.”

Behaviorists try to teach “responsible drinking,” with the unmistakable connotation that addictive drinking is “irresponsible.” “Harm reduction” is used as a guise for programs that give up on the need for abstinence. The shifting lexicon serves to blur the very substantial differences between alcohol and other drug dependence, and mental/behavioral problems.

ADPA’s paramount concern is the welfare of the suffering alcoholics and addicts in need of appropriate treatment by trained professionals and in chemical dependency programs geared specifically to address their primary diagnosis. Only these models, with proven track records, can offer hope of recovery and a life free from the consequences of alcoholism and drug dependence.

ADPA believes that public policy advocacy must be redoubled to preserve the integrity of treatment for alcohol and other drug dependence.

Of immediate concern is slippage at the state and local government levels where alcohol and drug dependency is at increasing risk of losing its bureaucratic visibility. When units with responsibility for alcohol and drug treatment programs are subsumed in low echelons under mental health, social services, or other departments, the focal point for advocacy is weakened or lost. The constituency of professionals and volunteers who serve as advocates for the alcohol and drug dependent are in danger of fragmentation.

Agencies charged specifically with programs for alcohol and drug dependency should have their discrete offices for training, communications, budgets, and other public policy functions. Alcohol and drug specialists need to be in a position to influence funding, programmatic, and personnel standards. Because of the pervasive nature of alcohol and other drug dependence, the agency, wherever it is located, must be able to impact policy across a wide range of health and human needs in the domain of departments staffed by personnel not trained to identify the problem. At the local level, where the bureaucratic structure tends to mirror that of the state, there is a critical need to retain control of clinical supervision, case decisions, and treatment protocols.

The Alcohol and Drug Problems Association believes that alcohol and drug dependence is a public health problem of major proportions costing society tens of billions of dollars in economic production, law enforcement, social services, health care and other areas. It exacts a terrible toll in terms of shattered lives of suffering alcoholics and addicts and their families. As such, when government at any level addresses alcohol and drug dependence, responsibility should be assigned to an agency of the highest visibility and independence where aggressive efforts can be mounted commensurate with the enormous dimensions of the problem. This was the inspired purpose of the Hughes Act programs 25-30 years ago, providing access to recovery for millions of alcoholics and addicts. A rededication to the spirit that moved those times may be needed to reestablish the powerful prevention and treatment impact from such organizational arrangements.

FOOTNOTE

1. National Institute on Drug Abuse “Principles of Drug Addiction Treatment, A Research Based C71lide,” NIH pub, No. 99-4181), October 1999.

2, Mark Schuckit. “Educating Yourself About Alcohol and Drugs! A People’s Primer” New York, 1995, “The conclusion from all these studies is basically the same. There is no evidence that people who later develop severe alcohol and drug problems are not more likely than others in the general population to have had severe depression, severe anxiety conditions, or psychotic conditions prior to the development of their alcohol and drug disorder.”

3. T George Verheal, Director of the Study of Adult Development, Harvard Medical School. and author of the 1983 milestone book, “The Natural History of Alcoholism,” is quoted in the March-April, 1999, issue of Harvard Magazine. “The addictive personality probably doesn’t exist…addictions tend to distort personalities. You can’t predict this. Alcoholics look like everyone else until they become alcoholics, much as cigarette smokers do,”

5. Paper from the “National Dialogue on Co-occurring Mental health and Substance Abuse Disorders,” June 16-17, 1998, Washington, DC, sponsored by the National Association of State Mental Health Program Directors and the National Association of State Alcohol and Drug Abuse Directors, and supported by the Center for Substance Abuse Treatment and the Mental Health Services Administration, Substance Abuse and Mental Health Services Administration. The Executive Summary states the following: “Estimates suggest that up to 10 million people in this country have a combination of at least one co-occurring mental health and substance-related disorder in any given year. There is no single locus of responsibility for people with co-occurring disorders. The mental health and substance abuse treatment systems operate independently of one another, as separate cultures, each with its own treatment philosophies, administrative structures and funding mechanisms. This lack of coordination means that neither consumers nor providers move easily among service settings.”

7. “Beyond the Influence – Understanding and Defeating Alcoholism,” by Katherine Ketcham and William F. Asbury with Mel Schulstad and Arthur P. Ciararnicoli, Ed-Ph-D., Bantam Books 2000, summarizes this research and offers the following definition of alcoholism: “Alcoholism is a progressive neurological disease strongly influenced by genetic vulnerability. Inherited or acquired abnormalities in brain chemistry create an altered response to alcohol which in turn causes a wide array of physical, psychological, and behavioral problems. Although environmental and social factors will influence the progression and expression of the disease, they are not in any sense causes of addictive drinking. Alcoholism is caused by biochemical/neuropsychological abnormalities that are passed down from one generation to the next or, in some cases, acquired through heavy or prolonged drinking.”

8. In April 1998, the Supreme Court, in a case brought by two veterans seeking disability benefits for alcoholism from the Department of Veterans Affairs, ruled that alcoholism was the result of “willful misconduct.” The decision cited a “substantial body” of literature contesting the concept that alcoholism is a disease “much less a disease for which the victim bears no responsibility.” The DVA recognizes alcoholism as a disability only when there is a primary psychiatric diagnosis.

9. National Institute on Drug Abuse “Principles of Drug Addiction Treatment, A Research Based Guide,” NIH Pub. No. 99-4 1 80, October 1999.